Advancing Cultural Competency and Equity in Surgical Specialties (ACCESS): A Model for a Combined Resident and Faculty DEI Initiative.

BACKGROUND: Committees dedicated to diversity, equity, and inclusion (DEI) are not commonplace within departments of surgery. Even rarer are joint initiatives for residents and faculty. We aim to describe the creation of a collaborative committee within a department of surgery to better foster and advance the ideals of DEI. METHODS: An informal needs-assessment was performed amongst the general surgery residency, advanced practice practitioners, and faculty. Other DEI groups throughout the institution were engaged for feedback and interdisciplinary collaboration. RESULTS: Gaps were identified in social support for those from diverse backgrounds, advocacy and recruitment, general DEI education, and research. Three pillars were formed: Social Support, Education and Advocacy, and Research. The overall group and each pillar are co-led by residents and faculty. In less than a year, the group has launched a cultural complications morbidity and mortality curriculum, hosted the first city-wide LGTBQ+ in surgery event, created a safe space for discussion and support, and advocated for recruitment DEI initiatives. So far, the group consists of 48 residents, faculty, advanced practice practitioners, and staff. CONCLUSIONS: An intentional, collaborative effort between residents and faculty in a department of surgery can successfully result in an effective partnership to advance DEI initiatives.

Perspectives of Surgical Research Residents on Improving Their Reentry Into Clinical Training.

OBJECTIVE: Concerns exist about clinical and operative skill decay in surgery residents when they dedicate time away from clinical training to pursue research. However, it remains undetermined how to best prevent these negative impacts. Our study evaluated the perspectives of surgical research residents on interventions to improve their reentry into clinical training. DESIGN, SETTING, AND PARTICIPANTS: An anonymous web-based survey was distributed between 5/01/2023 and 6/01/2023 to 102 current and former (within the previous 3 years) general surgery research residents from 4 academic medical centers in Boston, MA. RESULTS: Survey response rate was 35.3% (36/102 residents). About 22 of 36 residents (61.1%) felt that their clinical aptitude decreased during the research years, whereas 33 of 36 (91.7%) reported reduced surgical skills. When reflecting on their re-entry to residency, former research residents reported feeling anxious and less confident (3.84/5 on a 1-5 Likert scale) as well as being below the expected level of clinical performance (3.42/5). Most of them (12 of 17; 70.6%) reported that it took up to 6 months, whereas 5 of them (29.4%) up to 12 months to feel at the expected level. When compared to nonmoonlighting residents, those who moonlighted often and operated during moonlighting, denied a decrease in clinical and surgical skills, and reported less anxiety, higher confidence, and a quicker return to the expected level of performance. Interventions proposed for improving their clinical re-entry included individualized development plans for 3 months before returning to clinical training, established curriculum for clinical work throughout the research years, clinical preceptorships throughout the research years, and simulation curriculum throughout the research years. CONCLUSIONS: General surgery residents feel that their clinical and surgical skills decreased during the research years, leading to anxiety and lack of confidence when returning to residency. Therefore, comprehensive interventions are needed to improve the reentry of the research residents into clinical training.

Advancing Surgical Research for Immigrant Patients: A Call to Action.

Immigrants in the United States face unique challenges in accessing healthcare. There have been several studies highlighting some of the barriers that this population faces; however, there is still a lack of robust research on this patient population in the context of surgical access and outcomes. Immigration status is a protected variable that is not documented in patient charts for a myriad of reasons. This makes it incredibly difficult to identify this population in the first place, resulting in a decreased ability to study this group retrospectively and, therefore, restricting the quantity and quality of research into these vulnerable patients. This article aims to provide a call to action for medical professionals to develop ways to accurately document immigration status in medical records while simultaneously assuaging the concerns related to this documentation and its implications on patient care and confidentiality.

Observations on the Representation of Asians in Surgical Training and Leadership.

INTRODUCTION: Diversity in medicine has a positive effect on outcomes, especially for Asian patients. We sought to evaluate representation of Asians across entry and leadership levels in surgical training. METHODS: Publicly accessible population data from 2018 to 2023 were collected from the US Census Bureau, the Association of American Medical Colleges, and the American Board of Surgery (ABS). Frequencies based on self-identified Asian status were identified, and proportions were calculated. RESULTS: The US census showed Asians constituted 4.9% of the US population in 2018 versus 6% in 2023. The proportion of Asian medical students rose from 21.6% to 24.8%; however, Asian surgical residency applicants remained constant at 20%. ABS certifications of Asians have increased from 13.7% to 18.5%. ABS examiners increased from 15.7% to 17.1%. CONCLUSIONS: In 5 years, Asians have made numeric gains in medical school and surgical training. However, Asian representation lags at Board examiner levels compared to the medical student population. The ABS has made recent efforts at transparency around examiner and examinee characteristics. A pillar of ensuring a well-trained surgical workforce to serve the public is to mandate that all surgical trainees and graduates undergo fair examinations, and are fairly assessed on their qualifications. Observed progress should further invigorate all surgical applicants, residents and leadership to take an even more active role in making surgery more diverse and welcoming to all, by including careful analyses of diversity at all levels.

Retrieval of Embolized WATCHMAN® Flex Atrial Appendage Occlusion Device.

This case report documents the management of a 66-year old man with atrial fibrillation with recent placement of a WATCHMAN® Flex atrial appendage occlusion device. The patient presented with renal failure, abdominal pain, and difficulty walking 2 months after placement. The WATCHMAN® Flex device was found to have embolized to his abdominal aorta at the level of the renal arteries with associated thrombus. Extensive workup revealed reduced left ventricular cardiac function and decreased renal function, both of which were felt to be potentially reversible with device removal. The patient then underwent retrieval of the device and all associated thrombus via an open retroperitoneal approach. This case demonstrates a potential consequence of implanting devices such as an atrial appendage occlusion device and describes a technique for removal.

Comparing Healthcare Needs in Extremely Low Birth Weight Infants With NEC and Spontaneous Intestinal Perforation.

BACKGROUND: Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) affect 6-8% of extremely low birth weight (ELBW) infants. SIP has lower mortality than NEC, but with similar short-term morbidity in length of stay, growth failure, and supplemental oxygen requirements. Comparative long-term neurodevelopmental outcomes have not been clarified. METHODS: Data were prospectively collected from 59 North American neonatal units, regarding ELBW infants (401-1000 g or 22-27 weeks gestational age) born between 2011 and 2018 and evaluated again at 16-26 months corrected age. Outcomes were collected from infants with laparotomy-confirmed NEC, laparotomy-confirmed SIP, and those without NEC or SIP. The primary outcome was severe neurodevelopmental disability. Secondary outcomes were weight <10th percentile, medical readmission, post-discharge surgery and medical support at home. Adjusted risk ratios (ARR) were calculated. RESULTS: Of 13,673 ELBW infants, 6391 (47%) were followed including 93 of 232 (40%) with NEC and 100 of 235 (42%) with SIP. There were no statistically significant differences in adjusted risk of any outcomes when directly comparing NEC to SIP (ARR 2.35; 95% CI 0.89, 6.26). However, infants with NEC had greater risk of severe neurodevelopmental disability (ARR 1.43; 1.09-1.86), rehospitalization (ARR 1.46; 1.17-1.82), and post-discharge surgery (ARR 1.82; 1.48-2.23) compared to infants without NEC or SIP. Infants with SIP only had greater risk of post-discharge surgery (ARR 1.64; 1.34-2.00) compared to infants without NEC or SIP. CONCLUSIONS: ELBW infants with NEC had significantly increased risk of severe neurodevelopmental disability and post-discharge healthcare needs, consistent with prior literature. We now know infants with SIP also have increased healthcare needs. LEVELS OF EVIDENCE: Level II.

Predictors of Mortality in Very Low Birth Weight Neonates With Congenital Diaphragmatic Hernia.

BACKGROUND: Limited data exists regarding the mortality of very low birth weight (VLBW) neonates with congenital diaphragmatic hernia (CDH). This study aims to quantify and determine predictors of mortality in VLBW neonates with CDH. METHODS: This analysis of 829 U.S. NICUs included VLBW [birth weight ≤1500g] neonates, born 2011-2021 with and without CDH. The primary outcome was in-hospital mortality. A generalized estimating equation regression model determined the adjusted risk ratio (ARR) of mortality. RESULTS: Of 426,140 VLBW neonates, 535 had CDH. In neonates with CDH, 48.4% had an additional congenital anomaly vs 5.5% without. In-hospital mortality for neonates with CDH was 70.4% vs 12.6% without. Of those with CDH, 73.3% died by day of life 3. Of VLBW neonates with CDH, 38% were repaired. A subgroup analysis was performed on 60% of VLBW neonates who underwent delivery room intubation or mechanical ventilation, as an indicator of active treatment. Mortality in this group was 62.7% for neonates with CDH vs 16.4% without. Higher Apgars at 1 min and repair of CDH were associated with lower mortality (ARR 0.91; 95%CI 0.87,0.96 and ARR 0.28; 0.21,0.39). The presence of additional congenital anomalies was associated with higher mortality (ARR 1.14; 1.01,1.30). CONCLUSION: These benchmark data reveal that VLBW neonates with CDH have an extremely high mortality. Almost half of the cohort have an additional congenital anomaly which significantly increases the risk of death. This study may be utilized by providers and families to better understand the guarded prognosis of VLBW neonates with CDH. TYPE OF STUDY: Level II. LEVEL OF EVIDENCE: Level II.

Our Efforts to Create a Welcoming Surgical Residency for LGBTQ Trainees.

OBJECTIVE: To provide a more welcoming environment for LGBTQ residents. DESIGN: This paper is based upon the authors experience creating a training program welcoming to LGBTQ residents. SETTING: University General Surgery Training Program. PARTICIPANTS: Surgical Residents and Surgical Faculty. RESULTS: Over a 9 year period, our residency has made intentional efforts to welcome LGBTQ applicants and support LGBTQ residents. We now have a residency in which over 25% of our residents identify as LGBTQ. CONCLUSIONS: We see opportunities for other residencies to signal to applicants and trainees that they are welcome and celebrated for who they are.

Long-term assessment of bilirubin and transaminase trends in pediatric intestinal failure patients during the era of hepatoprotective parenteral nutrition.

PURPOSE: This study aimed to characterize the relationship between hepatoprotective parenteral nutrition (PN) dependence and long-term serum liver tests in children with intestinal failure (IF). METHODS: A retrospective review was performed of children with severe IF (> 90 consecutive days of PN) who were followed from 2012 to 2019 at a multidisciplinary intestinal rehabilitation program. Patients were stratified into three groups based on level of PN dependence at most recent follow up: EN (achieved enteral autonomy), mixed (parenteral and enteral nutrition), and PN (> 75% of caloric intake from PN). PN at any point for this cohort was hepatoprotective, defined as soy-based lipids < 1.5 g/kg/day, combination (soy, medium chain fatty acid, olive and fish oil) lipid emulsion, or fish oil-based lipid emulsion. Kaplan-Meier analysis and a generalized estimating equation (GEE) model were utilized to estimate time to normalization and trends, respectively, of two serum markers of liver health: direct bilirubin (DB) and alanine aminotransferase (ALT). RESULTS: The study included 123 patients (67 EN, 32 mixed, 24 PN). Median follow up time was 4 years. Based on the Kaplan Meier curve, 100% of EN and mixed group patients achieved normal DB levels by 3 years, while 32% of the PN group had elevated DB levels (Fig. 1). At 5 years, 16% of EN patients had elevated ALT levels compared to 73% of PN patients (p < 0.001, Fig. 2). The PN group's ALT levels were 1.76-fold above normal at 3 years (95%CI 1.48-2.03) and 1.65-fold above normal at 5 years (95%CI 1.33-1.97, Fig. 3). CONCLUSIONS: While serum bilirubin levels tend to normalize, long-term PN dependence in the era of hepatoprotective PN is associated with a persistent transaminase elevation in an overwhelming majority of patients. These data support continued vigilant monitoring of liver health in children with intestinal failure. LEVEL OF EVIDENCE: III.

Evaluation of a Preceptorship Model on Third-Year General Surgery Clerkship.

BACKGROUND: Medical students increasingly report not feeling meaningfully involved during surgical clerkships. Preceptorship and mentorship through longitudinal experiences ameliorate this problem. A preceptorship model was introduced into the surgery clerkship at our institution to increase contact and improve relationships between students and faculty. METHODS: The preceptorship model was introduced at select sites in 2017. In contrast to the standard structure in which students are assigned to cases and clinics as needed, preceptorship students are assigned to attending surgeons and follow the surgeons' schedules for the rotation. Student performance data, including final grades, clinical evaluations, and shelf examination scores, were collected for clerkship students from May 2017 to November 2018. Formative and summative evaluations for each student were collected. Qualitative content analysis was used to explore evaluations for themes. RESULTS: Two hundred and seventy-four students completed the clerkship during the study period; 41 experienced a preceptorship model. There was no difference in student performance across clerkship structures. Summative and formative evaluations for preceptorship students were longer than for traditional students (137 words vs 78 words; p < 0.0001 and 46 words vs 16 words, p = 0.03 respectively). Preceptorship student evaluations contained higher-quality feedback relating to clerkship objectives than those of traditional students. Preceptorship comments also contained more frequent mentions of response to feedback. CONCLUSIONS: A preceptorship model was successfully implemented on the third-year surgical clerkship at our institution. Although there was no difference between top performers on either clerkship structure, preceptorship students received written evaluations with better feedback as a result of their direct relationship with faculty. Strategies such as this, which improve student-faculty relationships, will be needed as programs find new ways to assess residency applicants.